Menorrhagia is a common gynecological complaint. Menorrhagia is defined as menstrual blood loss of >80 ml per menstrual period. This is an objective definition and is felt to represent a loss which, over a period of time, is likely to lead to iron deficiency anaemia. Objective assessment of blood loss is time consuming, not readily available and is not acceptable to the majority of patients in a clinical setting. The alternative subjective assessment is recognized as being an unreliable indicator of true menorrhagia. Higham in 1990, reported the use of a validated pictorial blood loss assessment chart in an attempt to provide a simple, accurate method of assessment of menstrual blood loss.
The chart records not only the number of towels and tampons used, but also takes into account the degree to which individual items were soiled with blood, and the passage of clots and associated flooding. From this chart it is possible to provide a score for each menstrual cycle. Using the Higham chart, a score>100 has a sensitivity of 86% and a specificity of 89% for the diagnosis of menorrhagia. The chart has been validated by correlating the pictorial chart score and the menstrual blood loss in ml using an alkaline haematin method for determination of menstrual blood loss.
The Higham chart has become the most commonly used pictorial chart. In their study they required patients to use the same type of internal and external protection (Tampax® and Kotex® Fems super plus tampons and Kotex® simplicity size 2 towels). The reason for this is that the capacity of different products to absorb blood varies widely and for this reason one of the conclusions of the paper is that the use of different sanitary protection may limit the use of the Higham pictorial chart. The chart can still be useful in clinical trials providing all the patients in the study are provided with the same sanitary protection. This allows for a direct comparison before and after medical intervention, but due to the potential differences in product absorption, does not allow a comment with regards the diagnosis of menorrhagia based on the Higham findings of a score of 100 (which represents 80 ml menstrual loss).
While the Higham chart was an advance that allowed patients to record their own blood loss in a user-friendly manner that didn't require collection of used menstrual product (as with alkaline hematin), the use of the Higham chart has been found to be unreliable due to the variation in the ability of the individual patients to score their own menstrual product.
What is needed, then, is an easy to use, outpatient method for the determination of menstrual blood loss in a reliable, accurate and precise manner.